Physician-Patient Contract for Marijuana Prescribing

[Pages:3]Physician-Patient Contract for Marijuana Prescribing

General

1. This is an agreement between______________________ and Dr.________________________ concerning the use of Marijuana for the treatment of _________________________________.

I, __________________________, request treatment of my condition with marijuana. As a result, I expect that I may become more functional and improve my quality of life. I have been treated with other therapies for my condition, which have not provided adequate relief of my symptoms.

2. I understand that marijuana is a strong drug and that there is insufficient scientific evidence to confirm its use for clinical purposes. There is also insufficient evidence on the clinical risks and benefits of this drug, including the proper dosage to be used for various medical conditions and symptoms, and the potential interactions between this drug and other medications. As such, I understand my physician may not be knowledgeable about all the risks associated with marijuana use.

Risks and Side Effects

3. I have been informed of the known risks and side effects of taking marijuana including, but not limited to: facial flushing, red eyes, dry mouth, drowsiness, sedation, dizziness, fainting, clumsiness, confusion, fuzzy thinking, impaired attention, impaired concentration, impaired short term memory, agitation, anxiety, paranoia, delusions, hallucinations, amnesia, fast or slow heartbeat.

4. When I first start taking marijuana, I may experience the adverse mood reactions noted above. With long term use of marijuana, the effects on attention, concentration and short term memory may worsen and can persist after I stop using marijuana.

5. If I smoke marijuana, I may develop a cough and/or wheeze which may persist with long term use and may result in lung damage.

6. I understand that some side effects of marijuana are made worse when used with other medication; for example drowsiness, sedation and dizziness are worse when marijuana are used with sleeping medication, tranquilizers, pain medications, antihistamines and seizure medications to name a few. I understand it is my responsibility to inform my physician of any and all side effects I have with this medication.

7. I understand that if I am pregnant or become pregnant while taking marijuana, my child may acquire behavioral and attention problems as a result of prenatal exposure to marijuana, as well as other unknown complications. It is believed there is also an increased risk of sudden infant death syndrome in babies born to mothers using marijuana in pregnancy.

Authorization (Prescription)

8. I agree to take marijuana as prescribed by my physician and not to change the amount or frequency of my marijuana use without first discussing it with my prescribing physician. Running out early, needing early refills, escalating doses without permission and losing any marijuana may be signs of misuse and may be reasons for my physician to discontinue prescribing marijuana to me.

9. I agree not to ask my physician for extra marijuana if I use up my supply early or if I lose or misplace my marijuana. I understand I will have to wait until the next allotment is due.

10. I agree that my marijuana will only be prescribed by Dr.______________________, unless in an absolute emergency, and if this be the case, I will inform Dr.______________________ as soon as possible.

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I understand I may access my marijuana in one of three ways: by registering with a licensed

producer, by registering with Health Canada to produce a limited amount for my own medical purposes, or by

registering with Health Canada designating someone else to produce my marijuana for me.

12. I agree not to accept marijuana from anyone, other than my Licensed Producer or my designated

producer.

13. If I decide to purchase from a Licensed Producer/Distributor, I agree to fill my prescription at only one

distributor: Name______________________________________,

Address ____________________________________,

Telephone number____________________________.

14. I agree to notify my physician if I change the means by which I obtain my marijuana.

15. I agree not to take any pain medications or mind altering medications other than those prescribed to

me by my physician Dr. ______________________. I will not seek such prescriptions from other

physicians.

16. I agree to tell any other physician who might treat me that I take marijuana for medical reasons.

17. I agree to tell my physician if I get any new medications prescribed to me by any other physician and if

any doses of my current medications are changed by another physician.

18. I agree not to drink alcohol or take other mood altering drugs (tranquilizers, sleeping pills, other mood

stabilizers) unless they are prescribed to me by my physician. I understand that using marijuana with

other drugs may lead to an overdose.

19. I agree to tell my physician all medications I am taking including over the counter drugs, herbs,

vitamins, etc.

Legal Implications

20. If marijuana causes me to become drowsy, sedated or dizzy, I understand I must not drive a motor vehicle (including all terrain vehicles, snowmobiles, boats) or operate machinery that could put my life or someone else's life in jeopardy. My physician has a legal obligation under Section 233 of the Highway traffic Act to inform the Registrar of Motor Vehicle of my clinical condition and that my treatment may make it dangerous for me to drive. If I do drive while using marijuana, I can be charged with Impaired Driving. If I am charged with impaired driving, while using marijuana, I agree that Dr. ___________________ is not to blame and will not be named in any resulting legal action. I accept full responsibility for any and all risks associated with the use of marijuana.

21. I agree to keep my marijuana in a safe and secure place, away from children. Lost, stolen or damaged marijuana will not be replaced. I will report any stolen marijuana to the police and my physician immediately.

22. I agree not to share, sell, lend, trade, transport/ship marijuana or in any way give my marijuana to any other person. I realize this is an illegal act. I also agree that my physician and my pharmacist may work with the police to look into any alleged misuse or sale of my marijuana.

23. I give permission to the above named physician to verify that I am not seeing other physicians for prescriptions of marijuana, opioids or other mind altering medications and to verify that I am only going to one licensed producer/distributor or one designated producer. It is illegal to obtain prescriptions for controlled substances and/or marijuana from two different physicians at the same time ("double doctoring").

24. I agree not to use any illegal drugs with my marijuana, including cocaine, crack, amphetamines (speed, crystal meth, ecstasy) and hallucinogens (LSD, mushrooms, PCP).

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Monitoring

25. I agree to submit to witnessed urine/saliva or blood specimens at any time that my physician requests and give my permission for them to be tested for alcohol and other drugs.

26. I agree to make appointments with my physician, at his/her office in person, at the time of renewal of my medical marijuana treatment.

27. I agree to attend all appointments that my doctor makes for me for tests, assessments and treatment with other healthcare workers, such as pharmacists, other doctors, physiotherapists, psychologists, addiction counsellors, etc. I consent to open communication between my doctor and any other healthcare professional involved in my healthcare.

28. I agree to a conference with my family or close friend(s), if my physician feels it is necessary and requests it.

Prescription Termination

29. I agree to attend all requested follow-up visits with my doctor to monitor my marijuana use and I understand that failure to do so could result in the discontinuation of my marijuana treatment.

30. I understand there is a risk of becoming addicted to marijuana. This means I might become psychologically dependent on marijuana, using it to alter my mood or get high. I may be unable to control my use of it. People with a past history of alcohol or drug problems are more susceptible to addiction. If this occurs, my marijuana prescription will be discontinued and I will be referred to a drug treatment program for help with this problem.

31. I understand that violent behavior or threats toward my physician, the staff or other patients is illegal and is not allowed. If this happens, my physician may stop prescribing medical marijuana to me. I may be asked to leave the office, and the police shall be called. (In addition, my physician may decide to stop providing me medical care altogether.)

32. If I violate this agreement, I understand that my physician may discontinue my marijuana treatment (and my physician may decide to stop providing me with medical care altogether.)

33. I understand my medical marijuana is prescribed as follows:

#grams/day:

_________________

Total # grams/month

_________________

(as per Health Canada's Marihuana for Medical Purposes Regulations recommendations)

34. I have read the above agreement and understand it. I have had the opportunity to ask any questions I have regarding medical marijuana and its use, in particular to my health condition. My concerns and questions have been addressed to my satisfaction by my physician.

Patient's signature:

_______________________________________

Prescriber/ Physician's signature:

_______________________________________

Date:

_______________________________________

Approved by Council, July 10, 2014, amended Sept 2014, amended Nov 30, 2016

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